Core Training in Anaesthesiology Portfolio

(1)

Core Training in Anaesthesiology

Portfolio

July 2018

D A S A I M

Danish Society of Anaesthesiology

and Intensive Care Medicine

(2)

2

Foreword

This portfolio contains templates for preparation of training plan; forms and competence cards for the mandatory workplace-based training assessments. Monitoring of whether the objectives for the training have been achieved are kept in logbog.net in the Curriculum for Specialist Training in Anaesthesiology - Core Training Programme. The following contains a short description of the procedures concerning workplace- based training assessment. The anaesthesia training manual contains a more detailed description of how the assessment is conducted in practice.

The portfolio for specialist training in anaesthesiology is produced by a designated work group under the Danish Society of Anaesthesiology and Intensive Care Medicine (DASAIM).

Rikke Borre Jacobsen

Chairman of the Educational Committee

Danish Society of Anaesthesiology and Intensive Care Medicine (DASAIM) July 2018

(4)

4

Workplace-based assessment

Plans for training

A training plan should be prepared for each core training element. Long-term elements can include several training plans.

General assessment and Mini Clinical Evaluation Exercise (Mini Cex)

During the training course, a regular formative general assessment and a formative Mini Cex are conducted of the trainee's handling and behaviour, i.e. how the trainee performs in practice. This assessment is related to the described competence objectives.

The general assessment and Mini Cex are conducted before the end of every relevant training element, such as thoracic anaesthesia, neuroanaesthesia, intensive care therapy, or after a more precise period of time. The schedules are included in the training programmes. It does not concern direct approval or non-approval following each element based on the above assessment. The assessment should be used to indicate areas where the trainee could improve or needs to make improvements. The supervisor should ensure that the interview is constructive and that the supervisor and the trainee at the end of the interview agree on possible focus areas. If an assessment is below the expected level, a written plan of action for improvements for the next assessment is prepared, as well as how and when the next assessment is conducted. At the end of each training element, the last (summative) general assessment and the last (summative) Mini Cex are conducted, and these are considered sufficient when the assessment of the competences is at or above the expected level. If the assessment indicates that this is unachievable, early measures have to be implemented, possibly in cooperation with the regional secretariat for continuing medical education, Det Regionale Videreuddannelsessekretariat. The general assessment also includes a continuous monitoring of quality of work, such as registration of experience.

The assessments are conducted in relation to the objectives with specification of the basis of assessment, which can include one or several of the following methods:

• Assessment using specific methods

• Observation of the trainee

• Review of record material

• Discussion with the trainee

• Feedback from others

• Other

Workplace-based training using specific methods

The training includes a number of mandatory specific assessments during the course of training.

Furthermore, in some cases the different wards and departments will choose to use specific methods for assessment of competences in selected areas. This will appear from the training programmes.

Observation of the trainee

Observation of the trainee during his/her work performance and the trainee's contribution at conferences and professional discussions etc. is an important source of information about his/her competences.

Review of record material

Records are an important source for assessment of the trainee's competences. It can be helpful to organise the review and in advance prepare for areas of interest. Record review combined with a discussion with the

(5)

5

trainee may be useful. The structured interview conducted by the supervisor could be based on record review with fixed subjects for discussion.

Discussion with the trainee

Regularly, the supervisor will discuss different issues and tasks with the trainee. These discussions serve to identify whether the trainee possesses the necessary background knowledge and is able to link this to practice. Finally, the discussion may include considerations regarding generalisation according to concrete examples. During the interviews the discussion is focused on whether the trainee's progress on training course is satisfactory. The logbook, the general assessment and Mini Cex are reviewed as documentation. This review is used as basis for assessment of all seven competences, especially expertise within the anaesthesia specialty.

Feedback from others

In many cases, the supervisor will not supervise the trainees directly during his/her work. This is partly due to logistic issues, and partly because it is important, that the trainee develops independence in his/her work.

In many cases, the supervisor will have to rely on statements about the trainee from other people. Several different people, who work closely with the trainee, would be able to provide different types of information regarding the trainee's competences.

Feedback regarding the trainee's work method from other people can be both positive and negative. It is the responsibility of the supervisor to ensure that the information is as valid and reliable as possible. It can be useful to specify the desired or available information and, if necessary, organise the collection of information.

Other

The portfolio can include several types of quality documentation of the work performance and of the way that different issues and tasks are being handled. For instance, it could be written statements from other people, course certificates, reports on management of particular issues, etc. The trainee presents this documentation to the supervisor when he/she is going to conduct the general assessment. The documentation is filed in the portfolio. The trainee is free to collect different types of documentation in the portfolio. It is recommended to collect documentation of specific activities, such as specific or complicated patients, management of difficult issues, statements from others, direct assessment of performances, prepared instructions for the department, QA projects, etc.

Cusum Scoring

Cusum Scoring of the four procedures: spinal anaesthesia, epidural anaesthesia, CVC, and artery needle are not mandatory during core training but can be useful to use in periods where the trainee or the clinical supervisor thinks that there are issues with the performance of one or more of the four procedures. The Cusum Scoring can be utilised as periodic tool for quality documentation of the procedures performed.

Experience registration and experience objectives

The trainee conducts continuous experience registration of selected performances in the anaesthesia specialty and patient categories after agreement with the head doctor responsible for education or the clinical supervisor of a given department or ward. Items for the experience registration are based on the key performances and patients treated. At the training interview the experience registration is reviewed to adjust the clinical activities to meet the experience registration objectives of the department. The consultant responsible for education or the clinical advisor then certifies the completion of the department's/ward's

(6)

6

requirement for the experience registration. This certification will be part of the overall assessment of the training course.

Registration of experience is an important tool for documentation of appropriate breadth and volume of clinical learning activities, and functions as a personal registration of whether a sufficient number of the different procedures have been completed. Additionally, experience registration serves as documentation of the necessary acquired breadth and volume. When starting in a department or ward (introductory interview), the procedures for experience registration and the number of procedures for completion are arranged in cooperation with the consultant responsible for education or the clinical supervisor.

Specific assessments

DASAIM recommends several mandatory specific assessments, which are included in this portfolio. The criteria for assessment are included in forms, which can be found in the portfolio. The specific assessments can be conducted by the primary supervisor or another supervisor.

In order to achieve an overall approval of the performance, the supervisor must be able to respond with YES to all items in a form. A YES next to an item means, that the item has been completed sufficiently and with sufficient quality. It is the responsibility of the individual supervisor to assess "the sufficiency" based on the supervisor's professional responsibility for good medical practice. Finally, the supervisor presents an overall assessment of the performance and decides whether it can be approved, and if so, he/she signs the map.

If the workplace-based training cannot be approved, the trainee will receive indications of areas where he/she needs to make improvements as well as the measures to achieve this. A new assessment is conducted when the trainee believes to be ready for this. If a performance cannot be approved after the third attempt, something is wrong, and the consultant responsible for education should be included in the assessment.

The trainee keeps the approved form as documentation and uploads it to logbog.net as documentation and presents it to the supervisor at the meetings. To receive approval for the entire training course, all specific objectives must be achieved.

Research training module

The organisation of the research training module is slightly different in the three regions. It consists of a common three-day standard module for all specialities. The graduate studies consist of a module with up to four days for courses and three days for seminars and presentation of a project plus 10 days for data collection, processing and preparation of a report. Time and method for the completion of the element are described in the training programme.

Certification of course participation

The course leaders certify in logbog.net that the courses have been completed sufficiently. It is the responsibility of the trainee to obtain the documentation in logbog.net.

Training course approval

The training is approved based on the collected documentation of competences, which can be found in the portfolio: general assessments, on-call competence (Mini Cex), certification of Cusum Scoring (when applied), and experience registration (when applied), specific competence assessments and certification of course participation. Obtained competences must be documented logbog.net in connection with supervisor interview. The procedure for application of recognition as specialist doctor can be found on SST.dk and logbog.net.

(7)

7

Certification of a training element from the consultant responsible for education

The consultant responsible for education in a department or a ward conducts an overall certification of the training element. Certification of timely completion of training element is given in logbog.net.

A training element is approved when the following has been completed:

1. The mandatory assessments included in the element must be "approved". Some assessments are achievable in several different elements, but from the training programme, it must be apparent which assessment should be completed and when. The trainee is obliged to upload approved competences in logbog.net.

2. The trainee scores "expected level" or "above expected level" in handling and behaviour in relation to the general objectives. If the trainee scores "below expected level", a written clarification and instruction for improvements must be presented, and the head doctor responsible for education must be informed – this should be done in agreement with the trainee.

3. The trainee has achieved appropriate breadth, volume and quality in relation to the objectives of the period. If the experience registration cannot be approved, a written clarification and instruction for improvements must be presented.

Approval of the specialist training by the consultant responsible for education

During the last training element, the consultant responsible for education conducts an overall assessment of the entire specialist training. This assessment is conducted together with the trainee. The assessment is conducted based on all documentation, i.e. approved mandatory assessments, the general assessments, Mini Cex, certification of course participation, and approved research training course. In the last general assessment and the last Mini Cex, the score should be "within expected level" or "above expected level". The last "Certification for completion of training element" is approved in logbog.net.

Please follow the instructions for application of recognition as specialist in anaesthesiology on SST.dk and logbog.net.

The core training can be approved if:

1. an overall assessment of the general assessments from the different constituent elements of the training can be approved. The decision is made in consultation with the trainee. If doubts exist, the secretariat for continuing medical education is included and often represented by the postgraduate clinical associate professor.

2. an overall assessment of trainee's experience breadth and volume can be approved.

3. certification of achievement of all specific objectives according to the logbook exists.

4. certification of participation in all mandatory courses exists.

5. approved research training element.

(8)

8

(9)

9

Overall list of workplace-based assessment

Competence Method Time

Expertise within the anaesthesia specialty General assessment Mini Cex

Training plan/report

Cusum Scoring/Experience registration

Following each clinical rotation stay Card Anaesthesia/perioperative medicine

1 Anaesthesia for major (open) abdominal surgery, ASA 3-4

Structured observation 2 Ultrasound guided peripheral nerve block Structured observation 3 Patient course description, ASA 3-5 patient, major

surgery

Reflective report 4 Thoracic anaesthesia, heart surgery Structured observation 5 Thoracic anaesthesia, pulmonary surgery Structured observation 6 Anaesthesia for vascular surgery Structured observation

7 Neuroanaesthesia Structured observation

8 Anaesthesia for children > 2 years Structured observation

9 Anaesthesia for section Structured observation

10 The bleeding patient Reflective report

11 Anaesthesia for a patient with expected difficult airway

Structured observation Intensive care therapy

12 Admission of new intensive care patient Structured observation 13 Ward rounds for complex intensive care patient Structured observation

14 Specific disease treatment – intensive care patient Structured conversation with supervisor 15 Quality regarding intensive care therapy Audit of 5 records

Pain management

16 Review of pain record - malignant/non-malignant pain

Structured conversation with supervisor Emergency, trauma and prehospital medicine

17 Emergency medical and trauma treatment Structured conversation with supervisor

Communication General assessment

On-call competence – Mini Cex

Following each clinical rotation stay

18 The difficult conversation Structured observation

Cooperation

Cooperation, conflict management General assessment

Organisation/management General assessment

Following each clinical rotation stay Organisation/management of workflow 360^o assessment

19 Management of work conferences Structured observation

Academic competence General assessment

Training plan/report

Oral presentation/lecture Research training project

Professionalism General assessment Following

each clinical rotation stay

20 Patient safety Reflective report

(10)

10

Plan for training

The trainee prepares the plan for the training and hands it to the supervisor at least three days prior to the meeting. The plan is discussed with the supervisor and may be adjusted later on. The plan is filed in the trainee's portfolio and can be uploaded to logbog.net.

Training plan for clinical stay

Name, Trainee ………..

Ward or department ...

Hospital ...

Period from ... to ...

Name, Trainee ...

Name, Supervisor ...

Date of the meeting ...

Date of the next meeting ...

Learning need/interest

Learning objective:

Which objectives are there for this time period?

Activities:

Which activities are needed to complete the objective, and when are they to be performed?

Assessment criteria:

Which type of

documentation should be collected to demonstrate that the objective has been completed?

(11)

11

Learning report

Following the end of the time period, the trainee prepares a report on the acquired knowledge according to the training plan. The report is given to the supervisor at least

three

days prior to the meeting and is then discussed. Is filed in the trainee's portfolio.

Training plan for clinical stay

Name, Trainee ………..

Ward or department ...

Hospital ...

Period from ... to ...

Name, Trainee ...

Name, Supervisor ...

Date of the meeting ...

Learning objective:

Which objectives have been completed for this time period?

Assessment criteria:

How has the completion of the objective been

documented?

Insufficiencies:

Which objectives have not been met?

Reason?

Could/should measures be implemented, and if so, which/how?

Reflection:

Thoughts and considerations of the course of training and the acquired knowledge.

Visions for the future, own and the profession's practice.

(12)

12

General assessment

Name, Trainee ...

Training element (hospital, department, ward) ...

Period: From date ... To date ...

During the past period, the trainee has demonstrated the following action way and behaviour:

Can not be asses-

sed 1 Poor

2 3 4 5 6 7 8 9

Excellent Below expected

level Expected level Above expected level Expertise within the anaesthesia specialty

Demonstrates a theoretical, clinical and situational knowledge and understanding in the handling of work and issues within the anaesthesia specialty.

Demonstrates sufficient clinical skills equivalent to the expected level.

....

….

Communication

Handles communication as characterised by understanding and respect for the recipient's wish and need for information and dialogue.

....

…. …. …. …. …. …. …. …. ….

Cooperation

Cooperates with others with respect and attention to their professionalism, situational roles and functions and contributes with own expertise.

....

…. …. …. …. …. …. …. …. ….

Organisation/management

Organises and prioritises work respecting demands for efficiency and safety in patient management and in consideration of own and organisational resources.

Assumes team leader position if appropriate.

....

…. …. …. …. …. …. …. …. ….

Academic competence

Demonstrates will and ability to continuously search for new knowledge, assess and develop own expertise as well as contribute to the development of other people and the profession in general.

....

…. …. …. …. …. …. …. …. ….

Professionalism

Demonstrates responsibility in the execution of practice in relation to patients, the organisation, the profession and the surroundings.

....

…. …. …. …. …. …. …. …. ….

Any comments and proposals for improvements must be present in case of assessment below expected level

Date: ... Signature: ...

(13)

13

General assessment (page 2 of 2) Name, Trainee:

The above general assessment is conducted based on one or more of the following methods:

Specific method (enclosed)

Observation of the trainee

Review of record material

Discussion with the trainee

Feedback from others

Other (please specify)

Any comments and proposals for improvements regarding handling and behaviour are enclosed: YES (must be available at assessments 1, 2 and 3)

Experience YES NO

The trainee has achieved appropriate breadth, volume, and quality in relation to the objectives of the period.

Cusum Scoring (enclosed)

Review of experience registration Observation of the trainee Discussion with the trainee Feedback from others Other (please specify)

Date: ... Signature: ...

(14)

14

On-call competence – Mini Clinical Evaluation Exercise (Mini Cex)

Name, Trainee ...

Training element (hospital, department, ward) ...

Date ... Assessed by supervisor ...

Focus (please choose): Team member function …….. Team leader function …... On-call execution/handling …..……..

Competence card:

This assessment of the trainee should be conducted during each training stay including on-call work, approx. four times a year, the appointed times can be found in the training programme. The trainee schedules the assessment with the on- call anaesthesiologist at the beginning of the shift. The focus of the assessment is arranged – team member function or team leader function or on-call execution. Prior to finishing the shift, the form is completed, and the specialist doctor gives constructive feedback with focus on development areas. The assessments should be present at the supervisor interviews.

During the last training stay, the assessment is conducted halfway through the stay. At this assessment, the assessments must be at expected level or above expected level. If this is not the case, the consultant responsible for education is involved and a plan of action is agreed upon, possibly with the involvement of the Continuing Medical Education (Den Lægelige Videreuddannelse).

During the past period, the trainee has demonstrated the following handling and behaviour:

Can not be asses-

sed

1

Poor 2 3 4 5 6 7 8 9

Excel- lent Below expected

level Expected level Above expected level Acquaints oneself with the on-call tasks

at the beginning of the shift .... …. …. …. …. …. …. …. …. ….

Prioritisation of tasks .... …. …. …. …. …. …. …. …. ….

Communication with team about execution of tasks

.... …. …. …. …. …. …. …. …. ….

Communication with collaborators from other departments

.... …. …. …. …. …. …. …. …. ….

Knowledge about own

competences/limitations – relevant request for assistance

.... …. …. …. …. …. …. …. …. ….

Sense of perspective and organising of tasks/resources

.... …. …. …. …. …. …. …. …. ….

Demonstrates receptiveness towards team member experience

.... …. …. …. …. …. …. …. …. ….

Contributes actively to constructive cooperation

.... …. …. …. …. …. …. …. …. ….

Feedback: Very good performance by the trainee

Feedback: Room for improvements by the trainee:

Feedback: Scheduled plan for improvements:

Any comments and proposals for improvements must be present in case of assessment below expected level

(15)

15

360° assessment regarding organisation, cooperation and communication

Name, Trainee ………

This assessment of the trainee should be conducted at least two times during the core training. It is conducted in an anaesthesia ward and/or an intensive care department during the sixth month of the core training and again when six months remains of the core training. The trainee hands out assessment forms to 10-15 persons who work closely with the trainee: six colleagues (older and younger), four anaesthetic/intensive care nurses, five other collaborators (e.g. surgeons, surgical nurses). The trainee selects the persons. The supervisor receives a list of the selected persons from the trainee.

The outline of the hand-out can be found on the next page. The response is sent (or e-mailed) to the trainee's supervisor. The trainee is responsible for ensuring that the respondents receive them name and address of the hospital (and e-mail address) of the supervisor.

The supervisor prepares an overall assessment based on the forms and uses the form on this page for summary. The overall assessment is reviewed at an interview conducted by the supervisor to which the trainee brings his/her self-assessment on the following page. The interview is a formative assessment where the trainee is provided with prospective feedback and strong points are emphasised. If improvements are required in one or several areas, the possibilities for this are discussed and a training plan is prepared, and a follow-up interview is scheduled. It may be useful for the supervisor to prepare for the interview in cooperation with the consultant responsible for education.

Satisfactory YES Treats patients politely and considerately

Uses situation-appropriate language

Listens actively and lets others participate in conversations

Communicates effectively with collaborator regarding plan for execution and prioritising of tasks

Is helpful and flexible

Utilises knowledge and experience from other staff members Prioritises own tasks rationally

Performs follow-up on own tasks

Demonstrates responsibility towards common tasks Completes own tasks in due time

Assesses own competences realistically and involves colleagues when necessary Has sense of perspective – is predictive in situations where special attention is required and reacts adequately in these

The overall assessment for this competence is approved

Supervisor's signature: Date:

(16)

16

360

⁰

assessment

As part of the assessment of my competence in the areas of communicator, collaborator and manager/organiser, I kindly ask you to fill in this questionnaire.

Name of anaesthesiologist: ...

All your answers are anonymous. However, we need to know your professional title – please tick the relevant box. Please add your name. This will only be visible to the trainee supervisor.

Anaesthesiologist, higher rank Anaesthesiologist, same rank Anaesthetic nurse

Recovery nurse Surgical nurse Surgeon

Other (please elaborate) Preferably name………

During the past period, the trainee has demonstrated the following handling and behaviour:

Can not be asses-

sed 1

Poor 2 3 4 5 6 7 8 9

Excellent Below expected

level

Expected level

Above expected level Treats patients politely and considerately

....

…. …. …. …. …. …. …. …. ….

Uses situation-appropriate language

....

…. …. …. …. …. …. …. …. ….

Listens actively and lets others participate in

conversations

....

…. …. …. …. …. …. …. …. ….

Communicates with collaborators regarding

plan for execution and prioritising of tasks

....

…. …. …. …. …. …. …. …. ….

Is helpful and flexible

....

…. …. …. …. …. …. …. …. ….

Utilises knowledge and experience from

other staff members

....

…. …. …. …. …. …. …. …. ….

Prioritises own tasks rationally

....

…. …. …. …. …. …. …. …. ….

Performs follow-up on own tasks

....

…. …. …. …. …. …. …. …. ….

Demonstrates responsibility towards

common tasks

....

…. …. …. …. …. …. …. …. ….

Completes own tasks in due time

....

…. …. …. …. …. …. …. …. ….

Assesses own competences realistically and

involves colleagues, when necessary

....

…. …. …. …. …. …. …. …. ….

Has sense of perspective – is predictive in situations where special attention is required and reacts adequately in these

....

…. …. …. …. …. …. …. …. ….

Please enter positive comments and/or suggestions for improvements on the back

(17)

17

CUSUM SCORE, qualitative scoring of performance

Name, Trainee: ………

Qualitative registration of success rate for: epidural, spinal, CVC, and artery needle. The form can be used during periods when you wish to Cusum Score one or more of the specified procedures. The scoring is applied as below, and a continuous summary is performed for each procedure. It is useful to complete the registration electronically, www.dasaim.dk.

Procedure and definition of "failed"

Epidural: failed is missing take, dura puncture or more than two passes. New pass is defined as at new level or shift from median to paramedian technique. Accidental pass in vessels does not count as a pass.

Spinal: failed is missing take or more than two passes, definition similar to epidural.

CVC: failed is new vein attempt.

Artery needle: failed is new artery attempt.

Epidural Spinal CVC A needle

Scores for fail + 0.93 + 0.86 + 0.91 + 0.71

Scores for success ÷ 0.07 ÷ 0.14 ÷ 0.09 ÷ 0.29

Max acceptable score + 2.94 + 2.71 + 1.81 + 2.24

Procedure number Epidural Spinal CVC A needle

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

(18)

18

Experience registration, qualitative registration of anaesthesia service

Please specify the following for each patient: Date, age, sex, ASA group, risk factors, type of surgery, elective/emergency, type of anaesthesia, procedures, complications

The form can be used to enter notes continually.

1

2

3

4

5

6

7

8

(19)

19

1 Anaesthesia for major (open) abdominal surgery, ASA 3-4 – structured observation

Name, Trainee ………..

This competence card is based on the trainee’s ability manage anaesthesia and postoperative treatment in patients undergoing major open surgery or a laparoscopic procedure in the abdomen (abdominal surgery, gynaecology, urology). Optimally, the trainee performs all of the preoperative course: preoperative anaesthetic assessment, management of following anaesthesia and the postoperative plan.

The supervisor observes the trainee during the practical course and performs continuous and subsequent assessment according to the items listed below.

Regardless of approved or failed competence, the supervisor provides specific and constructive feedback to the trainee.

YES Describes the ASA class of the patient based on comorbidity, treatment hereof and effect on

the planned operation

Presents a plan for the overall perioperative course

Accounts for type of anaesthesia, monitoring, procedures in relation to patients’ comorbidity and wishes for the upcoming surgical procedure

Provides anaesthesia in cooperation with surgical team

Communicates and cooperates adequately with the surgical team in the operating theatre in order for the team to have a common situation-awareness during the operation

Accounts for the most important complications related to the procedure as well as diagnosis and treatment

Performs transfer to postoperative ward and accounts for postoperative observation, possible complications and planned pain management

Accounts for considerations in connection with a theoretical case regarding

pneumoperitoneum (circulatory, respiratory and renally) and discussion of strategy for minimisation of morbidity and complications

Supervisor's signature: ……… Date ………..

(20)

20

2 Ultrasound guided peripheral nerve block – structured observation

This competence card is based on a structured observation which should demonstrate the trainee's ability to perform ultrasound guided peripheral nerve block for intraoperative and postoperative analgesia. Optimally, the trainee performs preoperative anaesthetic supervision and manages the following anaesthesia.

YES Accounts for preoperative assessment of the patient and usage of nerve block in the

perioperative course

Communicates adequately with the patient regarding the performance of the relevant peripheral nerve block and plan for anaesthesia for possible missing take

Describes basic functionality of ultrasound device and provides reasons for choice of transducer for the planned block

Demonstrates image optimisation and understanding of relevant sonoanatomy

Provides reasons for choice of block needle and demonstrates optimal imaging of needle and block in relation to relevant anatomic structures

Accounts for systemic side effects, overdose, toxicity, and complications as well as relevant prevention, diagnosis, and treatment of these

Tests block take sufficiently and describes plan for missing take

Describes indication, choice, and dosage of local anaesthetics, method for procedure and effects, side effects and complications of an upper extremity block, a lower extremity block and a trunk block

(21)

21

3 Patient course description, ASA 3-5 patient, major surgery – reflective report

The patient course description is meant to demonstrate the trainee's ability to assess practice and reflect on this in relation to theoretical, clinical, and situational knowledge and understanding.

The trainee chooses a patient course and manages the perioperative course. Based on a specific issue, the reflective report is prepared in relation to the choice of anaesthesia, monitoring or another issue that the trainee has been wondering about following the specific patient course. It could be an issue which developed during the course or a reflection on the practice of the department.

The issue is chosen with the supervisor. With focus on the chosen issue(s), a report on the patient course (max 10 pages in A4 format, 1.5 spacing), reflection and relevant references with a description in relation to the items listed below is prepared.

The chosen subject matter is elaborated in relation to relevant references, the applied practice and possible renewal of practice.

The report is submitted to the supervisor, who reviews it according to this form and provides a follow-up with specific and constructive oral and written feedback. Any lack of approval must be substantiated, and focus areas should be defined.

Assessment of the report based on the below items: YES

Describes the chosen patient course

Considers choices of monitoring and anaesthetic methods and accounts for potential difficulties or complications which could arise during the course

Accounts for the chosen issue

Accounts for the academic approach including literature search for accounting for theoretical considerations for the chosen issue

Accounts for the actual course of anaesthesia and recovery

Reflects on the theoretical, practical implications for other similar patient categories Reflects on the theoretical, practical implications for department practice

The report contains appropriate references

(22)

22

4 Thoracic anaesthesia, heart surgery – structured observation

This competence card is based on a structured observation which should demonstrate the trainee's ability to manage anaesthesia in patients undergoing heart surgery with use of extracorporeal circulation under supervision. Optimally, the trainee performs preoperative anaesthetic supervision and manages the following anaesthesia.

The supervisor observes the trainee during the practical course and performs continuous and subsequent assessment according to the items listed below. Regardless of approved or failed competence, the supervisor provides specific and constructive feedback to the trainee.

YES Accounts for patient's cardiac status and preoperative assessment

Discusses the correlation between the paraclinical cardiac examination results and the patient's clinical picture, functional level, symptoms, and clinical findings

Prepares a plan for perioperative management of patient and accounts for choice of strategy and method regarding anaesthesia, monitoring and perioperative treatment for the relevant heart surgery Performs anaesthesia and perioperative management – under supervision – including performing relevant procedures according to the statement of aims and performs relevant interpretation of monitoring data compared with clinical observations

Accounts for the most important complications in the initial postoperative phase, the prevention, diagnosis, and treatment of these

Accounts for haemodynamic variables and pathophysiological phenomena during placement of invasive haemodynamic monitoring

Discusses the most important methods for measuring/estimating cardiac output and their pros and cons Accounts for dose/effect of dopamine, adrenaline, dobutamine, noradrenaline, isoprenaline, milrinone, nitro-glycerine and beta blockers on the cardiovascular variables, including cardiac output and,

myocardial oxygen consumption

Accounts for how variations in heart rate and blood pressure affect the cardiac function in patients with aortic stenosis, patients with mitral insufficiency, patients with coronary atherosclerosis, and in patients with cardiac insufficiency

Discusses rational handling of a patient with mechanical valve, angina pectoris former AMI and EF or valve stenosis undergoing emergency abdominal surgery

(23)

23

5 Thoracic anaesthesia, pulmonary surgery – structured observation

This competence card is based on a structured observation which should demonstrate the trainee's ability to manage anaesthesia in patients undergoing pulmonary surgery with lung separation. Optimally, the trainee performs preoperative anaesthetic supervision and manages the following anaesthesia.

YES Accounts for patient's pulmonary status and preoperative assessment

Discusses the correlation between the paraclinical pulmonary examination results and the patient's clinical picture, functional level, symptoms, and clinical findings

Prepares a plan for perioperative management of patient, including account for choice of strategy and method regarding anaesthesia, monitoring and perioperative treatment for the relevant pulmonary surgery

Performs anaesthesia and perioperative management – under supervision – including performing relevant procedures and performing relevant interpretation of monitoring data

Accounts for the most important complications in the initial postoperative phase, the prevention, diagnosis and treatment of these

Discusses rational management of patient with severe pulmonary disease or single-lung, who is undergoing emergency abdominal surgery

Accounts for respiratory and haemodynamic variables and pathophysiological phenomena in connection with intubation, intermittent pressure ventilation and single-lung ventilation.

Accounts for shunt and dead space

Accounts for how intravenous anaesthetics, inhalation anaesthetics and epidural blockade affect VA/Q conditions and postoperative respiratory muscle function

(24)

24

6 Anaesthesia for vascular surgery – structured observation

This competence card is based on a structured observation which should demonstrate the trainee's ability to manage anaesthesia in patients undergoing vascular surgery under supervision. Optimally, the trainee performs preoperative anaesthetic supervision and manages the following anaesthesia. The supervisor observes the trainee during the practical course and performs continuous and subsequent assessment according to the items listed below. Regardless of approved or failed competence, the supervisor provides specific and constructive feedback to the trainee.

YES Accounts for special conditions in the patient group (characteristics, comorbidity) and special

areas of attention during the supervision of anaesthesia management

Compares the patient characteristics to the risk assessment and perioperative mortality Prepares a plan for perioperative handling of the patient and accounts for choice of strategy and method regarding anaesthesia, monitoring, blood component therapy as well as use of coagulation analysis

Performs anaesthesia and perioperative management – under supervision – including performing relevant procedures and performing relevant interpretation of monitoring data compared with clinical observations

Performs the perioperative course under supervision

Accounts for haemodynamic changes and measures to react on such in connection with clamping/opening aorta, including reperfusion syndrome

Accounts for the most significant risks and therapy objectives during the postoperative phase, prevention, diagnosis, and treatment for non-ruptured and ruptured AAA

Accounts for the risks of patient transport with ruptured AAA and describes patient preparation (monitoring, IV access, blood products, and personnel)

(25)

25

7 Neuroanaesthesia – structured observation

This competence card is based on a structured observation of (possibly several) patient course which should demonstrate the trainee's ability to manage anaesthesia in patients undergoing neurosurgery as well as monitoring and treatment of Increased Intracranial Pressure (ICP).

YES Prepares a plan for perioperative management of the patient including discussion of the rationale

behind the choice of anaesthetics as well as management of patient with increased intracranial pressure for intubation

Discusses the rationale for perioperative hyperventilation, including pros and cons

Accounts for the correlation between intracranial pressure, blood pressure and perfusion pressure Accounts for the effects of anaesthetics on the cerebral metabolism and cerebral blood flow

Accounts for at least three types of treatment for acute reduction of intracranial pressure Accounts for specific types of neurointensive observation and monitoring

Accounts for timely prioritisation and indication of neuroradiological examination and neurosurgical intervention in acute intracranial bleeding in relation to localisation and type of bleeding

Accounts for conditions regarding positioning which affect intracranial pressure

Utilises the Glasgow Coma Scale and accounts for the patient type relevant for the observations scale

Accounts for prognostic factors and indicators during the initial phase in patients with head trauma Discusses general considerations regarding primary admission as well as inter-hospital transfer of patient with intracranial bleeding and increased intracranial pressure

Accounts for specific conditions in prioritisation and initiation of treatment at scene of accident for patient with head trauma in relation to extracranial injuries

(26)

26

8 Anaesthesia for children > 2 years – structured observation

This competence card is based on a structured observation which should demonstrate the trainee's ability to manage anaesthesia in patients above two years of age. The trainee performs review of children in the pre, per- and postoperative course – optimally for the same child.

YES Formulates a plan for anaesthesia, including calculation of fluid, blood loss compensation,

anaesthetics, heat loss prevention and perioperative pain management

Accounts for rules for fasting period for children, disadvantages in long-term fasting, and factors that affect gastric emptying as well as accounts for rapid sequence induction for children Accounts for the specific conditions related to airway anatomy and standard tube sizes for different age groups of children

Discusses the rationale for choice of intubation vs. laryngeal mask airway in children in relation to surgery and comorbidity

Accounts for indication and practical execution of sedation

Discusses alternatives to IV administration of fluid and medication, and intraosseous infusion Utilises an appropriate sequence of anaesthetics for induction and utilises dilution of

medication in relation to the instructions of the department as well as utilises appropriate dose of anaesthetics for maintenance

Accounts for pharmacokinetics and -dynamics for the chosen pharmaceuticals Performs sufficient ventilation and intubation, including positioning of the head

Accounts for the most frequent causes of sudden hypoxia in children during anaesthesia and describe a troubleshooting algorithm as well as a plan of action

Communicates and cooperates adequately with the surgical team in the operating theatre in order for the team to have a common situation-awareness during the operation as well as prepares preoperative holding area and remedies adequately

Communicates adequately with the child and relatives and utilises techniques to prevent involuntary retention

Is orderly and systematic in the practical handling of the tasks

Accounts for specific ethical issues regarding informed consent of children The overall assessment for this competence is approved

(27)

27

9 Anaesthesia for sectio – structured observation

Name, Trainee ……….

This competence is based on a structured observation which should demonstrate the trainee's ability to manage anaesthesia in patients undergoing sectio. The trainee performs preoperative anaesthetic supervision, manages the following anaesthesia, and plans the postoperative pain management. The supervisor observes the trainee during the practical course and performs continuous and subsequent assessment according to the items listed below.

YES Accounts for the physical changes for pregnant women which affects the anaesthesia

Accounts for rules for fasting period and factors that affect gastric emptying in pregnant women Discusses choice of anaesthesia type: general vs. regional (spinal, epidural) in acute section (and formulates a plan for anaesthesia)

Communicates adequately with patient regarding the imminent sequence of events Manages relevant anaesthesia induction

Cooperates adequately with the team and communicates clearly on situation specific roles and tasks including preparation of preoperative holding area, remedies and table for resuscitation of newborns

Accounts for treatment of bleeding from atony

Accounts for specific precautions regarding anaesthesia induction in relation to effects on the child, partly directly through the used anaesthetics, partly indirectly through the effect on the circulation of the mother

Explains the guidelines for handling of newborns in relation to gestational age and Apgar scoring, including fluid management and standard dosing of adrenaline and naloxone

Accounts for specific precautions for anaesthesia in patient with pre-eclampsia and eclampsia Accounts for specific ethical dilemmas in acute sectio in relation to mother and child

(28)

28

10 The bleeding patient – reflective report

The reflective report serves to demonstrate the trainee's ability to assess a bleeding patient who requires balanced blood component therapy. The trainee is expected to respond critically to theoretical, clinical and situational knowledge and understanding.

The trainee chooses a patient course which he/she has participated in the management of. The reflective report is prepared based on record material, own experience of the situation, and any interview with collaborators.

The report should contain theoretical considerations in relation to the practical circumstances and conditions.

A report on the patient course is prepared (max 10 pages in A4 format, 1.5 spacing) which should contain a description of the items listed below. Please provide appropriate references.

The report is submitted to the supervisor, who reviews it according to this form and provides a follow-up with constructive and specific oral and written feedback. Any lack of approval must be substantiated, and focus areas should be defined.

Assessment of the report based on the items listed below YES

Describes shortly the patient and the relevant patient course Analyses the course:

• describes shortly deviations from the expected course

• discusses current and potential medical affect in patient coagulation in consideration of any comorbidity of the patient

• discusses possible clinical/paraclinical assessment of coagulation status

• relates to the transfusion strategy of the Danish Health Authority

• discusses current and potential transfusion

• discusses team resources and logistical considerations Discusses transfusion complications

Discusses the importance of patient’s coagulation status for in surgical and anaesthesiologic procedures

Accounts for medical and mechanical methods for minimising transfusion requirements Describes and discusses possible measures that were and could have been initiated Discusses how the management of the bleeding patient can contribute to individual and organisational learning and development

(29)

29

11 Anaesthesia for patient with expected difficult airway – structured observation

This competence card is based on a structured observation which should demonstrate the trainee's ability to manage anaesthesia for a patient with expected difficult airway. Optimally, the trainee manages all of the perioperative course: preoperative anaesthetic assessment, management of following anaesthesia and the postoperative plan.

YES Creates an overview of the pathoanatomic issue and the urgency of the procedure

Accounts for the plan for the airway management including relevant alternative plans Accounts for the choice of anaesthesia, devices, monitoring, and procedures

Performs anaesthesia in cooperation with the anaesthetic and surgical teams

Communicates and cooperates adequately with the surgical team in the operating theatre in order for the team to have a common situation-awareness during the airway management Accounts for the most important perioperative complications caused by the airway

management as well as diagnosis and treatment

Plans extubation and the postoperative course (observation, possible complications, and planned pain management)

Performs transfer to postoperative ward and accounts for postoperative plan Accounts for considerations in handling an emergency patient (awake or impaired

consciousness) with preserved respiratory drive who is suffering from haemorrhage or oedema in the upper airways: type of anaesthesia, airway management plans, devices, personnel resources including back-up at the hospital with or without ear, nose, and throat expertise Discusses differences between emergency airway management in the surgical ward and outside the surgical ward; type of anaesthesia, airway management plans, devices, personnel resources including back-up at the hospital with or without ear, nose, and throat expertise The overall assessment for this competence is approved

(30)

30

12 Admission of new intensive care patient – structured observation

This competence card is a structured observation which should demonstrate the trainee's ability to admit, initiate treatment and conduct a full assessment of a new intensive care patient.

The supervisor observes the trainee during the practical course and conducts a continuous and subsequent assessment according to the items listed below.

YES Conducts a systematic initial assessment of the patient with prioritisation of the immediate

measures

Initiates relevant monitoring

Assesses the airway and presents a plan for the airway management Initiates respiratory support therapy if indication is given

Initiates circulatory support therapy if indication is given Conducts adequate objective examination

Collects information via verbal handover and if possible, through the patient’s record on previous treatment and disease development and adjusts the treatment accordingly

Presents tentative diagnosis in collaboration with the relevant specialities and initiates relevant examination programme and treatment

Collaborates adequately with the team and communicates clearly on situation-specific roles and tasks in the patient treatment

Documents the course and treatment in the record The overall assessment for this competence is approved

(31)

31

13 Ward rounds for complex intensive care patient – structured observation

This competence is a structured observation which should demonstrate the trainee's ability to organise and perform ward rounds on a patient with failure of at least three organ systems.

The supervisor observes the trainee during the practical course with focus on the practical approach to the acute and critically ill intensive care patient and conducts continuous and subsequent assessment according to the items listed below.

YES Establishes the framework for ward rounds, clarifies who participate during ward rounds, and

agrees with the nursing staff how they are performed Reviews records, surveys the previous patient course Includes nursing staff observations and other information

Conducts a systematic, relevant and complete review of the clinical condition of the patient Handles continuous professional communication with the patient and staff

Identifies the most important issues for clarification with the team Summarises ward round with the team to identify:

• issues that have been treated/can be treated here and now

• issues that need further clarification before decision making (possible examinations, consultation of another colleague)

• issues that need handling during conference

• formulates a plan for the future course and criteria for adjustment of the plan

Arranges which type of information should be communicated at the conference, to the team on call or other colleagues, to the patient and any relatives or others

Ensures systematics and flow in practical handling of tasks Documents the course and treatment in the records The overall assessment for this competence is approved

(32)

32

14 Specific disease treatment - intensive care patient – structured conversation with supervisor

Name, Trainee ……….

This competence card is a structured conversation with supervisor which should demonstrate the trainee's ability to initiate and perform treatment of intensive care patients in the three major patient categories – sepsis, respiratory failure and renal insufficiency.

The conversation with the supervisor is based on intensive care record(s) of patient(s) with the above clinical pictures (can be three patients with individual problems or one patient with all three issues).

The supervisor and the trainee review the courses and organise the interview based on the sub-items below.

YES Selects the relevant issues

By sepsis:

• defines sepsis and septic shock

• accounts for Surviving Sepsis Campaign Guidelines and the core for treatment of the septic patient

• monitors the septic patient accordingly

By respiratory failure:

• accounts for indications for and contraindications to invasive and non-invasive mechanical ventilation types

• accounts for different modes of mechanical ventilation

• accounts for initial ventilation strategy for patients who are admitted to the intensive care ward

• defines and accounts for the ARDS condition and for lung protective ventilation

• accounts for respirator step down principles, including daily wake-up-call and SBT (spontaneous breathing trials)

• accounts for possible complications of respirator treatment

By renal insufficiency:

• accounts for indication areas for and contraindications to starting CRRT

• accounts for the different types of CRRT

• accounts for complications of CRRT

• accounts for different possibilities for anticoagulation for CRRT

• accounts for initial settings on the CRRT equipment The overall assessment for this competence is approved

Core Training in Anaesthesiology Portfolio